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Abstract

Background: Prior studies have documented racial differences in the use of evidence-based acute therapy and revascularization among those with non-ST-segment elevation myocardial infarction (NSTEMI). It is unclear how these differences in acute care affect short- and long-term outcomes.

Methods: We linked clinical data from the CRUSADE registry to Medicare claims information to create a longitudinal record of care and outcomes for NSTEMI patients aged 65 and over. These data were used to examine 30-day and long-term (median follow-up 2.5 years) outcomes among 38,528 NSTEMI patients treated at 446 hospitals between 2003 and 2006. Unadjusted and adjusted mortality and readmission rates were then compared between blacks and whites.

Results: Compared with whites (n= 35,559), blacks (n= 2,969, 7.7%) were younger and more often female. Blacks more frequently had hypertension, diabetes, obesity, and more often required hemodialysis. They were slightly less likely than whites to receive class I guideline-indicated NSTEMI therapy; specifically, blacks received clopidogrel and glycoprotein IIb/IIIa inhibitors less often. Additionally, they were also less likely to undergo in-hospital percutaneous (23.6% vs. 32.1%, p<0.0001) or surgical (5.6% vs. 9.1%, p<0.0001) revascularization. Despite these differences, blacks had both lower unadjusted and risk-adjusted mortality rates than whites through 30 days. However, on long-term follow-up, blacks had higher unadjusted mortality than whites. These differences were no longer significant after adjusting for differences in comorbidities (table).

Conclusions: The early survival advantage seen in elderly blacks over whites with NSTEMI is lost over follow-up where long-term risk of mortality is higher among blacks. This is likely attributed to differences in major comorbidities, in-hospital, and discharge treatments in this population.